Online Application

THIS APPLICATION IS FOR CARROLL COUNTY ILLINOIS ONLY and must be submitted electronically using this system to create a receipt of application. Paper applications available upon request as a Reasonable Accommodation.

ADDITIONAL HOUSEHOLD MEMBERS

Instructions List ALL persons, other than the Head of Household identified above, who will be living in the home. Please, provide information for adults first, then children under age 18. Select relationship of each person to the Head of Household.

HOUSEHOLD INCOME INFORMATION

Instructions

List total gross income (before taxes) and payments received by each household member age 18 or older. Include all earnings and benefits received from AFDC/TANF, Social Security, SSI, SSID, employment, unemployment, worker’s compensation, child support, military pay, Veterans Affairs, pensions, business, profession, or any other source.

At least one source of income must be specified. If you do not have any income, enter 0 for "Gross Annual Income".

Name *

Gross Annual Income *

Name/Address Source of Income *

Name

Gross Annual Income

Name/Address Source of Income

Name

Gross Annual Income

Name/Address Source of Income

Name

Gross Annual Income

Name/Address Source of Income

Name

Gross Annual Income

Name/Address Source of Income

Name

Gross Annual Income

Name/Address Source of Income

HOUSEHOLD ASSETS INFORMATION

Instructions List the total cash value and total income received for assets owned by ALL household members combined.

Checking Accounts

Annual Income Received from Asset

Savings Accounts

Annual Income Received from Asset

Stocks, Bonds, CDs, Investments

Annual Income Received from Asset

Real Estate

Annual Income Received from Asset

Other

Annual Income Received from Asset

PREVIOUS HOUSING INFORMATION

Instructions List current and/or previous landlord references in order from most recent to oldest.

Name of Landlord *

Address of Landlord *

Phone Number of Landlord *

Length of Tenancy *

Name of Landlord

Address of Landlord

Phone Number of Landlord

Length of Tenancy

Name of Landlord

Address of Landlord

Phone Number of Landlord

Length of Tenancy

OPTIONAL CONTACT INFORMATION

Instructions

You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Commitment of Housing Authority: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Name

Address

Phone Number

Email Address

LEGAL NOTICE OF CERTIFICATION AND CONSENT

GIVING TRUE AND COMPLETE INFORMATION
I certify, under penalty of perjury, that all the information provided on household composition, income, family assets, items for allowances and deductions, is accurate and complete to the best of my knowledge. I have reviewed the application form and the HUD Form 50058 or 50059, which ever applies to me, and certify the information provided is true and correct.

REPORTING ON PRIOR HOUSING ASSISTANCE
I certify, under penalty of perjury, that I have disclosed where I received any previous Federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information, or vacate the unit in violation of the lease.

NO DUPLICATE RESIDENCE OR ASSISTANCE
I certify, under penalty of perjury, the house or apartment will be my principal residence and will not obtain duplicate Federal housing assistance while I am in this current program.

CRIMINAL AND ADMINISTRATIVE ACTIONS FOR FALSE INFORMATION
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly making false statements or misrepresentation to any department or agency of the United States.

I understand and agree that knowingly supplying false, incomplete, or inaccurate information is punishable under Federal and/or State criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance and/or termination of tenancy.

COOPERATION
I understand and agree that I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances.I understand and agree that cooperation includes attending pre-scheduled meetings and/or completing and signing needed forms.I understand and agree that failure or refusal to do so may result in delays, termination of assistance, or eviction.

REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION
I understand and agree that I am required to report changes in income and any changes in the housing size when a person moves in or out of the unit. I understand the rules regarding guests/visitors and when I must report anyone who is staying with me.

CONSENT FOR RELEASE OF INFORMATION
I hereby authorize and direct any Federal, State, or local agency, organization, business, or individual to release any information or materials to Carroll County Housing Authority that are needed to complete and verify my application for participation, and/or maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-Income Public and/or Indian Housing, and/or housing assistance programs. I understand and agree this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies.

INFORMATION COVERED
I understand and agree that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquires that may be requested, include but are not limited to: Identity, Marital Status, Employment, Income, Assets, Residences & Rental Activity, Medical and Child Care Allowances, Credit, and Criminal Activity. I understand and agree this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in housing assistance program.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED
I understand and agree the groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to: Previous Landlords (including Public Housing Agencies), Courts & Post Offices, Schools & Colleges, Law Enforcement Agencies, Past and Present Employers, Welfare Agencies, State Unemployment Agencies, Social Security Administration, Medical & Childcare Providers, Veterans Administration, Retirement Systems, Banks & Other Financial Institutions, Credit Providers & Bureaus, and Utility Companies.

COMPUTER MATCHING NOTICE & CONSENT
I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I have a right to notification of any adverse information found and a chance to disprove that information. HUD may in the course of its duties exchange such automated information with other Federal, State or local agencies, including but not limited to: State Employment Security Agencies, Department of Defense, Office of Personnel Management, the U.S. Postal Service Agency, and State welfare and food stamp agencies.

CONDITIONS
I understand and agree that a copy of this authorization may be used for the purposes stated above. The authorization will stay in affect for a year and one month from the date signed.

ELECTRONIC SIGNATURE
I understand and agree that, under the Uniform Electronic Transactions Act (UETA) and the Electronic Signatures in Global and National Commerce Act (ESIGN) [Title 15 Chapter 96 of the United States Code], submitting this application constitutes an electronic signature and possesses the same legal effect and consequence as a handwritten signature.